The Simple Technique of Sternal Closure Using An Absorbable Mesh Plate.

BACKGROUND: Several authors have investigated various sternal closure materials and technologies for sternal fixation; nonetheless, the optimal technique for primary sternal closure remains unclear. This study aimed to evaluate the sternal stability of a simple technique using a mesh-type plate (Super Fixorb MX40®; Takiron Co. Ltd., Osaka, Japan), as compared with wire cerclage. METHODS: A total of 70 patients who underwent cardiovascular surgery through median sternotomy between July 2019 and May 2020 were included. Two pieces of mesh-type plates were placed under the sternum in combination with wiring. The technique for sternal closure was randomly applied, which was mainly based on the surgeon's preferences: mesh plate (mesh group: N = 33) or conventional wire cerclage (wire group: N = 37). Sternal displacement was measured using computed tomography at discharge. RESULTS: Pain scale scores and analgesic use on postoperative day 7 were similar between the two groups. However, the displacement in both the anterior-posterior and lateral directions was significantly smaller in the mesh group. CONCLUSIONS: The use of the mesh plate device for sternal closure is simple, safe, easy, and potentially reliable without anterior-posterior sternal displacement.

Early and mid-term results of transcatheter aortic valve implantation and valve durability assessment.

This study aimed to evaluate the early and mid-term outcomes of transcatheter aortic valve implantation (TAVI) and to assess valve durability. A total of 146 consecutive patients who underwent TAVI for severe aortic stenosis between October 2013 and August 2018 were retrospectively reviewed. All patients (mean age, 84 ± 6 years; age range 53-98 years; 42 males [28.7%]) had multiple comorbidities, with a mean logistic EuroSCORE of 30.9 ± 17.4%. Eighteen patients (12.3%) were aged 90 years or over. Five in-hospital deaths (3.4%) occurred, and 36 patients (24.7%) experienced major TAVI-related complications. With the transfemoral approach, 10 patients had major vascular complications, which mostly occurred with first-generation devices (n = 9) but less commonly with new-generation low-profile devices (P = 0.0078). During a follow-up period of 580 ± 450 (11-1738) days, 29 late deaths occurred. The survival rate was 86.0%, 78.0%, and 61.7% at 1, 2, and 3 years, respectively. Multivariate Cox hazard regression analysis revealed that more-than-moderate tricuspid regurgitation was the only independent risk factor for late deaths due to any cause (hazard ratio, 3.145; 95% confidence interval, 1.129-8.762; P = 0.0283). No statistically significant differences between post-TAVI before discharge from the hospital and at 4 years after TAVI were observed with respect to aortic valve area (1.76 ± 0.49 cm2 vs. 1.64 ± 0.38 cm2; P = 0.1871) and mean pressure gradient (10.0 ± 4.6 mmHg vs. 7.9 ± 3.3 mmHg; P = 0.5032). TAVI was a feasible method with acceptable early and mid-term outcomes and valve durability for at least 4 years in poor-risk patients. Further close follow-up is essential to evaluate late outcomes and valve durability.

Correction to: Aortic remodeling with frozen elephant trunk technique for Stanford type A aortic dissection using Japanese J-graft open stent graft.

The article Aortic remodeling with frozen elephant trunk technique for Stanford type A aortic dissection using Japanese J-graft open stent graft, written by Masato Tochii, Yoshiyuki Takami, Hiroshi Ishikawa, Michiko Ishida, Yoshiro Higuchi, Yusuke Sakurai, Kentaro Amano and Yasushi Takagi was originally published electronically on the publisher's internet portal (currently SpringerLink) on 06 September 2018 without open access. With the author(s)' decision to opt for Open Choice the copyright of the article changed on 26 September 2018 to © The Author(s) 2018 and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made. In addition, the Table 2 was published incorrectly in the original publication of the article and the correct Table 2 is provided.

Aortic remodeling with frozen elephant trunk technique for Stanford type A aortic dissection using Japanese J-graft open stent graft.

The frozen elephant trunk (FET) technique allows single-stage extended surgical repair of Stanford type A aortic dissection and has shown promotion of aortic remodeling by maintaining the true lumen flow and facilitating its expansion and by promoting false lumen thrombosis. However, few studies have compared the effectiveness of FET technique, in terms of the downstream aortic remodeling. Between 2005 and 2017, 50 patients underwent total arch replacement for Stanford type A aortic dissection, including that with (n = 22) and without FET technique (n = 28). We compared distal aortic remodeling in patients who underwent total arch replacement with (using a J-Graft open stent graft) or without the technique. The false lumen complete thrombosis rate and the ratio of true lumen area at three levels of the descending aorta were evaluated post operation. In FET group, the diameter and length of the stent graft were 29.0 ± 3.9 mm and 70.9 ± 17.4 mm, respectively. The in-hospital death with and without the FET technique was 0 and 3, respectively, with no late death in both groups. Eight patients (28.6%) only in the non-FET group required additional surgical treatment for downstream aorta. In the FET group, the ratio of true lumen area at the level of bronchial carina and false lumen complete thrombosis rate at the levels of bronchial carina and aortic valve were significantly higher than non-FET group. A more favorable remodeling in the descending aorta was observed in patients who underwent FET associated with a total arch replacement compared to those who underwent total arch replacement alone.

Distal Limited Open Stenting for Aortic Diverticulum in the Right Aortic Arch.

An aortic diverticulum, including Kommerell's diverticulum, is an uncommon, congenital, aortic arch anomaly. Surgery for a diverticulum is challenging, and several surgical strategies have been reported. Here, we present the case of an asymptomatic 57-year-old man who was referred to our hospital. Computed tomography revealed right aortic arch and aortic diverticulum, and he underwent distal limited open stenting under hypothermic circulatory arrest with selective cerebral perfusion via median sternotomy. The postoperative course was uneventful. Thus, this report shows that our procedure is useful and safe for treating aortic diverticulum.

Early and Late Outcomes of Surgical Repair for Stanford A Acute Aortic Dissection in Octogenarians.

BACKGROUND: Because increased age is a strong independent predictor of mortality and morbidity, surgery for octogenarians with Stanford type A aortic dissection (AAD) may be avoided.Methods and Results:From 2005 to 2015, 158 patients underwent surgical repair for AAD via a median sternotomy. We compared 24 (15.2%) octogenarians (83±3 years) with 134 (84.8%) patients aged ≤79 years (62±13 years), based on retrospectively collected clinical data. Octogenarians were predominantly female (79.2% vs. 44.8%, P=0.0033). Ascending aortic replacement was more frequently performed in the octogenarians (95.8% vs. 65.7%, P=0.0015) and total arch replacement in the younger patients (4.2% vs. 26.9%, P=0.0165). There were 14 hospital deaths among the younger patients, none among the octogenarians (0% vs. 10.4%, P=0.1303), and major morbidity rates were comparable. There were 3 late deaths among the octogenarians and 9 deaths among the younger patients. The respective 1-, 3-, and 5-year survival rates were 94.4%, 81.5%, and 81.5% in the octogenarians and 86.9%, 85.6%, and 83.9% in the younger patients, with no significant differences. CONCLUSIONS: Surgical repair for AAD in octogenarians showed favorable results when compared with a younger patient cohort, with low hospital mortality rate and excellent late outcomes. Therefore, this technique should not be disregarded just because the patient is an octogenarian. (Circ J 2016; 80: 2468-2472).

Impact of postoperative cerebral complications in acute infective endocarditis: a retrospective single-center study.

BACKGROUND: The treatment of patients with infective endocarditis (IE) who have preoperative cerebral complications remains less understood. Therefore, this study aimed to retrospectively evaluate the clinical outcomes of patients with acute IE based on preoperative intracranial findings. METHODS: Of 32 patients with acute IE treated at our hospital between August 2015 and March 2022, 31 patients of whom preoperative intracranial imaging evaluation was available were included in our analysis and compared with those with and without intracranial findings. We controlled the mean arterial blood pressure and activated clotting time (ACT) to prevent abnormally high perfusion pressures and ACTs during cardiopulmonary bypass (CPB). The preoperative background, and postoperative courses focusing on postoperative brain complications were reviewed. RESULTS: Among the 31 patients, 20 (65%) had preoperative imaging findings. The group with intracranial findings was significantly older, with more embolisms in other organs, positive intraoperative pathology findings, and longer CPB times. A new cerebral hemorrhage developed postoperatively in one patient without intracranial findings. There were no early deaths; two patients had recurrent infections in each group, and one died because of sepsis in the late phase in the group with intracranial findings. CONCLUSIONS: Positive intracranial findings indicated significantly active infectious conditions preoperatively but did not affect the postoperative course. Patients without preoperative cerebral complications can develop serious cerebral hemorrhage. Although meticulous examination of preoperative cerebral complications in all patients with IE is essential, a strategy should be adopted to prevent cerebral hemorrhage, even in patients without intracranial findings.

Fracture and embolization of a metal stent after a frozen elephant trunk procedure.

The Frozenix J graft open stent graft has been available since 2014 in Japan. This stent is widely used for the frozen elephant trunk technique in many institutions, mainly for cases of acute type A aortic dissection and also for cases of a true aneurysm and chronic aortic dissection. We treated a rare case in which the metal wires of the Frozenix J graft were broken and embolized to the periphery half a year after being implanted.

Effective treatment of severe stenosis of the carotid and coronary arteries: a case study.

It is considered acceptable to conservatively manage coronary artery bypass grafting patients with carotid artery disease without the need for preoperative corrective carotid revascularization. However, in the present case, rapidly progressive stroke symptoms with penumbra suggested in the arterial spin labeling, carotid artery stenting was performed successfully.

Outcomes after valve-preserving root surgery for patients with Marfan syndrome.

BACKGROUND AND AIM OF THE STUDY: In patients with Marfan syndrome (MFS), valve reimplantation has been proposed as superior to root remodeling. In the present study, both forms of valve-preserving root repair were applied and mid-term results analyzed in MFS patients compared to a propensity score-matched cohort. METHODS: Among 604 patients who underwent valve-preserving aortic root surgery between 1995 and 2011 at the authors' institution, 33 MFS patients (16 males, 17 females; mean age 31 +/- 12 years) underwent either remodeling (n=21) or reimplantation (n=12). All patients were followed up echocardiographically, and the outcome with regard to late aortic valve regurgitation (AR) grade EII and reoperation on the aortic valve was compared between MFS patients and the matched cohort (n=33). RESULTS: Baseline characteristics and operative data were similar between the groups. Actuarial freedom from AR > or = II at seven years was 86 +/- 8% in MFS patients and 90 +/- 10% in matched non-MFS patients (p = 0.94). Actuarial freedom from reoperation at seven years was 90 +/- 7% in MFS patients and 100% in non-MFS patients (p = 0.79). In Cox's proportional hazard's model, no independent risk factor, including MFS, was found for recurrent AR or reoperation. Within the MFS patients, remodeling and reimplantation provided an almost identical freedom from late AR > or = II and reoperation up to five years postoperatively (p = 0.55 and 0.99, respectively). CONCLUSION: The stability of valve-preserving aortic root repair was comparable between patients with or without MFS. Both forms of valve-preserving root repair can provide similar mid-term results for MFS patients, primarily according to their root geometry. However, additional long-term follow up data based on a larger number of patients are required to confirm the evidence obtained to date.

A modified sutureless repair for left pulmonary vein obstruction after catheter ablation.

A 52-year-old man presented with temporal haemoptysis and chest pain 6 months after radiofrequency catheter ablation for atrial fibrillation. Computed tomography revealed severe stenosis in the left upper pulmonary vein (PV) and complete occlusion of the left lower PV. A modified sutureless repair of the left PV obstruction was successfully performed. This modified procedure provides a feasible, safe and effective means of treating PV obstruction, even in cases with distal extension of stenosis.

Free-wall perforation of the left ventricle after acute myocardial infarction complicated with pericardial tamponade that mimicked ascending aortic dissection: A case report.

Life-threatening cardiac events may be misdiagnosed as acute aortic dissection because of notable symptom mimicry. We report the case of a 72-year-old male patient with presentations presumed to be of aortic origin. However, surgery revealed posterior free-wall perforation in the left ventricle caused by the occlusion of an obtuse marginal branch.

Ventricular septal rupture after blunt chest trauma: a case report.

Cardiac injury, including myocardial contusion and valvular damage, is a common complication of blunt chest trauma; however, traumatic ventricular septal rupture is a rare complication. We encountered a rare case of ventricular septal rupture following blunt chest trauma that was successfully repaired by emergency surgery. The mechanism underlying rupture may involve acute compression of the heart between the sternum and the vertebral column when the ventricle is filled, thereby causing a sudden increase in intraventricular pressure and leading to septal rupture. Emergency operation should be considered in cases of large defects and hemodynamic instability.

Impact of GERAADA score in patients with acute type A aortic dissection.

BACKGROUND: Despite continuous developments and advances in the perioperative management of patients suffering from acute aortic dissection type A (AADA), the associated postoperative morbidity and mortality remain high and strongly depend on the preoperative clinical status. The associated postoperative mortality is still hard to predict prior to the surgical procedure. The so-called German Registry of Acute Aortic Dissection Type A (GERAADA) score uses very basic and easily retrievable parameters and was specifically designed for predicting the 30-day mortality rate in patients undergoing surgery for AADA. This study evaluated impact of the GERAADA score in the authors' institutional results. METHODS: Among 101 acute type A aortic dissection patients treated at our hospital during August 2015-March 2021, the GERAADA was calculated individually and retrospectively. Predicted and actual mortalities were assessed, and independent predicted factors were searched. The primary endpoint was defined as comparison of GERAADA scores and early mortality, and the secondary endpoints were defined as comparison of GERAADA scores and other postoperative results, and comparison of preoperative factors and postoperative results regardless to GERAADA scores. RESULTS: While the overall 30-day mortality for the entire study cohort calculated by the GERAADA score was 14.3 (8.1-77.6)%, the actual mortality rate was 6%. However, the GERAADA score was significantly high in some postoperative complications and showed significant correlation with some peri- and post-operative factors. In addition, factors not belonging to GERAADA score such as time from onset to arrival at the hospital, time from onset to arrival at the operation room, spouse presence, and hemodialysis were significantly associated with 30-day mortality. CONCLUSIONS: Although the actual mortality was lower than predicted, GERAADA score may impact on the postoperative course. In addition, it would be desirable to add parameters such as the time from onset to arrival, family background, and hemodialysis for further accuracy.

Impact of the Isolated Cerebral Perfusion Technique for Aortic Arch Aneurysm Repair in Patients with a Shaggy Aorta.

Objective: Total aortic arch replacement (TAR), particularly in individuals with extensive atherosclerotic alterations, especially shaggy aortas, is more crucial and difficult. The objective of this retrospective investigation was to ascertain if patients with shaggy aortas would respond to modified isolated cerebral perfusion (ICP). Materials and Methods: Between 2015 and 2020, nine individuals with shaggy aortas who received treatment for arch aneurysms were examined. Four and five patients, respectively, who had arch replacement with traditional selective cerebral perfusion (SCP) and modified ICP, were evaluated, and their short- and long-term results were compared. Results: There were no appreciable variations in the postoperative results between patients with traditional SCP and those with modified ICP. Following surgery, one patient developed paraparesis, while two individuals with traditional SCP experienced persistent neurological damage. In patients with modified ICP, there were no postoperative neurological or other problems associated to atherosclerosis; nevertheless, one patient experienced stroke 5 months after surgery. Conclusion: Patients with shaggy aorta may not receive enough brain protection from TAR with standard SCP because single axillary artery perfusion can result in nonphysiological flow and atheroma separation. Even in patients with shaggy aortas, TAR with modified ICP is safe, but late-phase severe adverse cerebrovascular events should be taken into account.

The change in the mitral-septal angle after surgery for atrial functional mitral regurgitation.

OBJECTIVE: The optimal surgical strategy for atrial functional mitral regurgitation remains uncertain. Preoperative mitral-septal angle ≤ 70° has been reported as a risk factor for an abnormal vortex pattern in mitral valve repair. This study aimed to elucidate the change in the mitral-septal angle after surgery for atrial functional mitral regurgitation and its effect on the mid-term outcomes. METHODS: Forty patients underwent mitral valve repair for atrial functional mitral regurgitation. The mitral-septal angle was defined as the angle between the mitral annulus and the anteroseptal wall of the left ventricular mid-portion in the parasternal long-axis view on transthoracic echocardiography. All patients underwent mitral ring annuloplasty. Left atrial plication was performed in nine patients. The mean clinical follow-up period was 42 ± 24 months. RESULTS: The ratio of left atrial volume to left ventricular end-systolic volume was negatively correlated with the preoperative mitral-septal angle. The postoperative mitral-septal angles were significantly smaller than the preoperative ones. The mitral-septal angle decreased with a decrease in the mitral annuloplasty ring size. Patients who underwent left atrial plication tended to show an increase in the mitral-septal angle postoperatively. There were no significant differences in mid-term morbidities, including heart failure, requiring re-hospitalization and mortalities between patients with postoperative MSA > 70° and those with postoperative MSA ≤ 70°. CONCLUSIONS: Mitral ring annuloplasty negatively changed the mitral-septal angle, while left atrial plication may induce a positive change to the mitral-septal angle. An association between the mitral-septal angle and mid-term outcomes was not revealed in this study.

Midterm results of mitral valve repair for atrial functional mitral regurgitation: a retrospective study.

BACKGROUND: Annular dilation by left atrial remodeling is considered the main cause of atrial function mitral regurgitation. Although acceptable outcomes have been obtained using mitral ring annuloplasty alone for atrial functional mitral regurgitation, data assessing outcomes of this procedure are limited. Therefore, we aimed to assess midterm outcomes of mitral valve repair in patients with atrial functional mitral regurgitation. METHODS: We retrospectively studied 40 patients (mean age: 69 ± 9 years) who had atrial fibrillation that persisted for > 1 year, preserved left ventricular ejection fraction of > 40%, and mitral valve repair for atrial functional mitral regurgitation. The mean clinical follow-up duration was 42 ± 24 months. RESULTS: Mitral ring annuloplasty was performed for all patients. Additional repair including anterior mitral leaflet neochordoplasty was performed for 22 patients. Concomitant procedures included maze procedure in 20 patients and tricuspid ring annuloplasty in 31 patients. Follow-up echocardiography showed significant decreases in left atrial dimensions and left ventricular end-diastolic dimensions. Recurrent mitral regurgitation due to ring detachment or leaflet tethering was observed in five patients and was seen more frequently among those with preoperative left ventricular dilatation. Three patients without tricuspid ring annuloplasty or sinus rhythm recovery by maze procedure developed significant tricuspid regurgitation. Five patients who underwent the maze procedure showed sinus rhythm recovery. Rates of freedom from re-admission for heart failure at 1 and 5 years after surgery were 95 and 86%, respectively. CONCLUSIONS: Mitral valve repair is not sufficient to prevent recurrent atrial functional mitral regurgitation in patients with preoperative left ventricular dilatation. Tricuspid ring annuloplasty may be required for long-term prevention of significant tricuspid regurgitation.

Early First-Generation Trifecta Valve Failure: A Case Series and a Review of the Literature.

BACKGROUND: The Trifecta valve (Abbott, St Paul, MN) has excellent hemodynamic performance with acceptable rates of freedom from structural valve degeneration. However, some recent studies have reported early Trifecta valve failure. Here, we report a case series of seven Trifecta valve failures with a review of the literature. METHODS: Of 107 implantations of Trifecta bioprostheses between 2012 and 2014, we encountered seven Trifecta valve failures (6.5%). Failure of a 19-mm Trifecta valve occurred in 1 patient, failure of a 21-mm Trifecta valve occurred in 5 patients, and failure of a 23-mm Trifecta valve occurred in 1 patient. The mean duration of valve durability was 51 ± 16 months. The mean effective orifice area index on the first echocardiogram after Trifecta valve implantation was 0.96 ± 0.26. The mode of presentation was prosthetic valve stenosis in 3 patients and severe aortic regurgitation in 4 patients. RESULTS: Six patients underwent redo surgical aortic valve replacement. The common pathologic findings were circumferential pannus formation with noncoronary cusp tear and leaflet calcification. The rates of preoperative end-renal stage disease and postoperative prosthesis-patient mismatch were higher in patients with Trifecta valve failure. The incidence of early Trifecta valve failure was 3.1% at 48 months and 13.1% at 72 months. CONCLUSIONS: In our experience, early Trifecta valve failure was caused by cusp tears or leaflet calcification. Patients with end-renal stage disease and prosthesis-patient mismatch should be closely followed. Some patients with cusp tears may require urgent surgery.

Lower body ischaemic time is a risk factor for acute kidney injury after surgery for type A acute aortic dissection.

OBJECTIVES: Postoperative acute kidney injury (AKI) is known as a risk factor for death after surgery for Stanford type A acute aortic dissection under hypothermic circulatory arrest. It may also adversely affect long-term survival. We searched for modifiable risk factors for postoperative AKI, focusing on lower body ischaemic time. METHODS: We reviewed 191 patients undergoing surgical repair for Stanford type A acute aortic dissection. The distal anastomosis depended on excluding the primary tear location, resulting in ascending/hemiarch (n = 119), partial arch (n = 18) and total arch replacement (n = 54). We defined an increase in the serum creatinine level to ≧2 times the baseline level as AKI. The incidence of AKI was investigated with multivariate analysis of its risk factors. RESULTS: Postoperative AKI was observed in 49 patients (26%), 31% of whom required renal replacement therapy. The overall hospital mortality rate was 8.5%. Postoperative AKI, preoperative shock and organ malperfusion were predictors of hospital death. Multivariate stepwise logistic regression analysis identified age, body mass index, preoperative chronic kidney disease and lower body ischaemic time as risk factors for postoperative AKI. CONCLUSIONS: Although surgical repair for Stanford type A acute aortic dissection showed favourable results, the incidence of postoperative AKI is still high, closely associated with hospital death. Lower body ischaemic time should be recognized specifically as a modifiable surgical risk factor for postoperative AKI.

Early and long-term results of total arch replacement with the frozen elephant trunk technique for acute type A aortic dissection.

OBJECTIVES: We evaluated the operative and long-term outcomes of the frozen elephant trunk (FET) technique for acute type A aortic dissection. METHODS: This study evaluated 426 consecutive patients who underwent aortic repair for acute type A aortic dissection from June 2007 to December 2018 at our centre. Of these, 139 patients underwent total arch replacement with FET (FET group), and 287 underwent other procedures (no FET group). Ninety-two patients in the FET group were matched to 92 patients in the no FET group by using propensity score matching analysis. RESULTS: Thirty-day mortality and neurological dysfunction were not significantly different between the FET and no FET groups (1.4% vs 2.4%, P = 0.50 and 5.0% vs 6.3%, P = 0.61, respectively). Long-term survival was better in the FET group than in the no FET group (P = 0.008). Freedom from distal thoracic reintervention was similar in the FET and no FET groups (P = 0.74). In the propensity-matched patients, freedom from aortic-related death was better in the FET group than in the no FET group (P = 0.044). CONCLUSIONS: Operative outcomes showed no significant difference between the 2 groups. FET contributes to better long-term survival in patients with acute type A aortic dissection.